Traumatic hyphema: Difference between revisions

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*Should be made by the ophthalmologist after examining the patient
*Should be made by the ophthalmologist after examining the patient
**Hyphemas <33% of anterior chamber are frequently managed as outpatients
**Hyphemas <33% of anterior chamber are frequently managed as outpatients
*Patients being managed as an outpatient should have ophthalmologist referral and consider outpatient screening for spontaneous hypthemas due to the association with [[sickle cell disease]] and [[hemophilia]]


==Prognosis==
==Prognosis==

Revision as of 21:49, 27 August 2016

Background

  • Grossly visible blood in the anterior chamber of the eye
  • Typically caused by blunt trauma to the orbit
  • Can result in permanent vision loss
    • Outcome dependent on prevention of rebleeding and control of intraocular pressure
  • In non-traumatic hyphema, all black patients should be screened for sickle cell disease with hemoglobin electrophoresis

Clinical Features

Hyphema, Grade II-III
  • Vision loss
    • Earliest symptom is decreased vision
  • Eye pain
  • History of trauma to eye
  • Direct and consensual photophobia
  • Nausea and Vomiting
  • Hyphema grading correlates to IOP increase[1]
    • Grade 0 to IV
    • 13.5% have IOP increase in Grade I to II
    • 52% with IOP increase in Grade IV
Hyphema grading.JPG

Differential Diagnosis

Maxillofacial Trauma

Unilateral red eye

^Emergent diagnoses ^^Critical diagnoses

Spontaneous hyphema (non-traumatic hyphema)

Evaluation

evaluation is best performed under slit-lamp exam

  • Blood in anterior chamber
    • May only see difference in color of irises if patient is supine because blood layering is gravity dependent
    • Blood in anterior chamber only visible on slit lamp is a microhyphema
  • Vision loss / Acuity changes
  • Inspect the lids, lashes, lacrimal ducts, and cornea
    • Corneal abrasions often co-exist
  • Assess direct and consensual pupillary response for the presence of a relative afferent pupillary defect
  • Assess for Ruptured Globe which is associated with high energy mechanisms (shrapnel, BB guns, paint balls, etc)
  • Check intraocular pressure after Globe Rupture is excluded
  • Inquire about bleeding diathesis, anticoagulant/NSAID/aspirin use

Management

  • Elevate head of bed and upright position to layer blood by gravity, open visual field while blood resorbs
  • Eye shield
  • Pharmacologic control of pain and emesis
  • Weigh risks and benefits of stopping NSAIDs, ASA, anticoagulants
  • Consult ophtho regarding:
    • Dilation of pupil to avoid "pupillary play"
      • Constriction and dilation movements of the iris in response to changing lighting
      • Can stretch the involved iris vessel causing additional bleeding
    • Use of topical alpha-agonists and/or acetazolamide to decrease intraocular pressure
  • No reading (accommodation may further stress injured blood vessels)
  • Cycloplegic
    • For comfort if globe rupture has been excluded
  • Topical steroid
  • Treat any underlying coagulopathy
  • If IOP elevated:
    • Timolol
    • Topical alpha-adrenergic agonist
    • Carbonic anhydrase inhibitors

Disposition

  • Should be made by the ophthalmologist after examining the patient
    • Hyphemas <33% of anterior chamber are frequently managed as outpatients
  • Patients being managed as an outpatient should have ophthalmologist referral and consider outpatient screening for spontaneous hypthemas due to the association with sickle cell disease and hemophilia

Prognosis

  • Rebleeding worsens prognosis as patients are at higher risk of permanent vision loss.
    • Occurs 3-5 days after initial incident
    • Complicates ~30% of cases
    • Populations at highest risk:
      • Sickle Cell disease or sickle cell trait
      • Bleeding dyscrasia (including aspirin, NSAID, or anticoagulant use)
      • Initial intraocular pressure >22 mmHg
      • Pediatric patients
Grade Anterior Chamber Filling Normal Vision Prognosis
I <33% 90%
II 33-50% 70%
III >50% 50%
IV 100% 50%

See Also

Video

{{#widget:YouTube|id=vQG9kL7mpyA}}

References